School Counseling Termination Activities Questionnaire Form
For school counseling staff to document termination activities at the end of counseling services.
Staff Name
*
First Name
Last Name
Student Initials or ID (do not use full name)
*
Date of Termination Session
*
-
Month
-
Day
Year
Date
Reason for Termination
*
Planned completion
Student moved/withdrew
Parent/guardian request
Other
Termination Activities Completed (select all that apply)
*
Reviewed progress toward goals
Discussed transition plan
Provided resources/referrals
Collected feedback from student
Other
How ready is the student for termination?
*
1
2
3
4
5
To what extent were the counseling goals met?
*
Not at all
1
2
3
4
Completely
5
1 is Not at all, 5 is Completely
Summary of Counseling Progress
*
Counseling Strategies Used and Their Effectiveness
Rows
Strategy Used
Effectiveness (1=Not effective, 5=Highly effective)
Strategy 1
Strategy 2
Strategy 3
Additional Comments or Recommendations
Submit
Should be Empty: